Justia Public Benefits Opinion Summaries

Procopio served aboard the U.S.S. Intrepid in 1964-1967. In July 1966, the Intrepid was deployed in the waters offshore the landmass of the Republic of Vietnam, including its territorial sea. Procopio sought entitlement to service connection for diabetes mellitus in 2006 and for prostate cancer in 2007 but was denied service connection for both in 2009. The Federal Circuit reversed, holding that the unambiguous language of the Agent Orange Act, 38 U.S.C. 1116, entitles Procopio to a presumption of service connection for his prostate cancer and diabetes mellitus. The term “in the Republic of Vietnam,” unambiguously includes the territorial sea under all available international law. Congress indicated those who served in the 12 nautical mile territorial sea of the “Republic of Vietnam” are entitled to section 1116’s presumption if they meet the section’s other requirements. View "Procopio v. Wilkie" on Justia Law

Ashlee Oldham and Robert Prunckun (collectively, “Recipients”) were the only two Delaware Medicaid recipients housed at Judge Rotenberg Center (“JRC”), a facility in Massachusetts and the only facility in the United States known to use electric shock therapy as part of their comprehensive behavioral treatment plans. These services were covered by Medicaid with the knowledge and approval of Delaware’s Department of Health and Social Services (“DHSS”). in 2012, the Center for Medicare and Medicaid Services (“CMS”) advised the Massachusetts state agency responsible for Medicaid administration that continued use of electric shock therapy would place that state’s waiver program in jeopardy of losing federal funding. Following CMS’s letter to Massachusetts, Delaware took measures to avoid placing its own Home and Community Based Services (“HCBS”) waiver program at risk. DHSS finally terminated JRC as a qualified provider after JRC refused to cease using electric shock therapy. Although the procedural history was complex, the gist of Appellants’ challenge on appeal to the Delaware Supreme Court was that they were denied due process because Delaware’s administrative hearing officer bifurcated proceedings to address what she concluded was a threshold issue, namely, whether electric shock therapy was a covered Medicaid service under the Medicaid HCBS Waiver program. Instead, Recipients contended they should have been allowed to introduce evidence that electric shock therapy was medically necessary, and that by removing shock services, DHSS threatened Recipients’ ability to remain in a community-based setting (a conclusion they desired to prove through evidence and expert testimony). The Supreme Court determined the hearing officer's determination that electric shock therapy was not a covered service under federal and state law was supported by substantial evidence and free from legal error, and affirmed the district court. View "Prunckun v. Delaware Dept. of Health & Social Services" on Justia Law

Neighbors is a skilled nursing facility participating in Medicare and Medicaid. The Centers for Medicare and Medicaid Services (CMS) determined that Neighbors inadequately addressed sexual interactions between three cognitively impaired residents and that Neighbors’ failure to act put the residents in “immediate jeopardy,” and issued Neighbors a citation and an $83,800 penalty under 42 U.S.C. 1395i‐3(h)(2)(B)(ii)(I). An ALJ and the Department of Health and Human Services Departmental Appeals Board upheld the decision. The Seventh Circuit affirmed, concluding that substantial evidence supports the Agency’s determinations and rejecting claims that the sexual interactions were consensual. The court noted findings that staff, aware of the sexual interactions, did not talk to the residents about their feelings about these “relationships”; did not document the residents’ capacity for consent (or lack thereof) or communicate with residents’ physicians for medical assessment of how their cognitive deficits impacted that capacity; did not discuss the developments with the residents’ responsible parties; and did not record any monitoring of the behaviors or make any care plans to account for them. Neighbors’ non‐intervention policy prevented any real inquiry into consent, except in the extreme situation where a resident was yelling or physically acting out. View "Neighbors Rehabilitation Center, LLC v. United States Department of Health and Human Services" on Justia Law

Wilkerson mined coal for over 25 years. In 1994, he retired from the Island Creek’s Crescent mine, where he had worked most recently as an electrician. In 2012, Wilkers sought benefits under the Black Lung Benefits Act, which provides compensation to miners disabled by pneumoconiosis, 30 U.S.C. 902(b), 922(a)(1). The Sixth Circuit denied a petition for review, upholding the Benefits Review Board’s award of benefits. The defendant forfeited an argument that the ALJ lacked authority to hear the case under the Appointments Clause by failing to raise it in its opening brief. Appointments Clause challenges arise under the U.S. Constitution, but are “not jurisdictional and thus are subject to ordinary principles of waiver and forfeiture.” Substantial evidence supports the award. An ALJ may presume an applicant suffers from the disease if he worked for 15 years at a qualifying coaling mine and suffers “a totally disabling respiratory or pulmonary impairment.” Wilkerson worked for more than 15 years at a qualifying mine, and substantial evidence showed that he suffered total disability due to a respiratory or pulmonary impairment. Faced with the conflicting medical evidence, the ALJ turned to the four doctors who testified, credited testimony from one doctor, discounted the three others for legitimate reasons, and concluded that Wilkerson suffered from a disability. The doctor’s conclusion about Wilkerson’s disability tracked the newest available data. View "Island Creek Coal Co. v. Wilkerson" on Justia Law

The Supreme Court affirmed the judgment of the district court affirming the position of the Iowa Department of Human Services (DHS) determining that transfers made by Petitioners, nursing home residents, to a pooled special needs trust were for less than fair market value and required a delay in Petitioners’ eligibility for Medicaid benefits, holding that the district court and DHS correctly construed and applied federal law requiring the delay in Medicaid benefits for long-term institutional care.Federal eligibility requirements provide that state ensure that Medicaid benefits are reserved for persons who lack financial means and have not transferred personal asserts that could pay for their care. Petitioners, at age sixty-five, transferred more than one-half million dollars to a pooled special needs trust. The Supreme Court held that the district court and DHS properly interpreted federal law effectively requiring Petitioner’s to tap their pooled trust assets first to pay for their nursing home care. View "Cox v. Iowa Department of Human Services" on Justia Law

The Tennessee Hospital Association and three hospitals sued, challenging efforts by the Centers for Medicare and Medicaid Services (CMS) to direct states to recoup certain reimbursements made under the Medicaid program. The hospitals serve a disproportionate share of Medicaid-eligible patients and are thereby entitled to supplemental payments under the Medicaid Act, (DSH payments), 42 U.S.C. 1396a(a)(13)(A)(iv); 1396r-4(b). The Act limits the amount of DSH payments each hospital can receive in a given year. CMS contends that the hospitals miscalculated their DSH payment-adjustments for fiscal year 2012 and received extra payments. Plaintiffs argued, and the district court agreed, that CMS’s approach to calculating DSH payment adjustments is inconsistent with the Act and the regulations that CMS implemented in 2008. The Sixth Circuit affirmed, agreeing that CMS’s policy is inconsistent with its 2008 rule and cannot be enforced unless it is promulgated pursuant to notice-and-comment rulemaking. The court disagreed with the district court’s conclusion that CMS’s policy exceeds the agency’s authority under the Medicaid Act. CMS’s payment-deduction policy is a reasonable interpretation of an ambiguous section of the Act but is not a valid interpretative rule. CMS attempted to exercise its delegated discretion to “determine[]” the “costs incurred” in serving Medicaid-eligible patients—precisely the sort of agency action that requires notice-and-comment rulemaking. View "Tennessee Hospital Association v. Azar" on Justia Law

In April 2009, E.O. visited a pediatrician for his six-month visit and received several vaccinations. That night, Mrs. Oliver found E.O. seizing in his bed and called 9-1-1. At the emergency room, E.O. presented with a fever, red eyes with discharge, and a runny nose. The next day, E.O.’s pediatrician diagnosed E.O. with “complex febrile seizure and conjunctivitis.” E.O. did not have any health issues or seizures for two months but had several seizures over the summer and began to experience prolonged seizures in March 2010. Each seizure resulted in an emergency room visit. A pediatric neurologist diagnosed E.O. with an SCN1A gene defect. E.O. exhibited developmental delay. A pediatric neurologist performed examinations, which demonstrated “intractable, symptomatic childhood absence and complex partial seizures of independent hemisphere origin secondary to SCN1A gene defect (borderline SMEI syndrome) and encephalopathy characterized by speech delay.” E.O.’s family sought compensation under the National Childhood Vaccine Injury Act, 42 U.S.C. 300aa-2–300aa-33, alleging that E.O. developed Dravet syndrome as a result of the vaccinations. The Claims Court and Federal Circuit affirmed the rejection of their claim. The government’s expert provided strong evidence that Dravet syndrome will develop in children with the SCN[1]A mutation, whether or not they receive vaccinations; the Olivers failed to establish that their theory has garnered widespread acceptance, as evidenced by an extensive discussion of articles with contradictory findings. View "Oliver v. Secretary of Health and Human Services" on Justia Law

This matter stemmed from a lawsuit filed by the State of Mississippi against the defendant pharmacies. The State alleged deceptive trade practices and fraudulent reporting of inflated “usual and customary” prices in the defendant’s reimbursement requests to the Mississippi Department of Medicaid. The State argued that Walgreens, CVS, and Fred’s pharmacies purposefully misrepresented these prices to obtain higher prescription drug reimbursements from the State. Finding that the circuit court was better equipped to preside over this action, the DeSoto County Chancery Court transferred the matter to the DeSoto County Circuit Court in response to the defendants’ request. Aggrieved, the State timely filed an interlocutory appeal disputing the chancellor’s decision to transfer the case. After a thorough review of the parties’ positions, the Mississippi Supreme Court found that though the chancery court properly could have retained the action, the chancellor correctly used his discretion to transfer the case, allowing the issues to proceed in front of a circuit-court jury. As a result, the Supreme Court affirmed the chancellor’s decision. View "Mississippi v. Walgreen Co." on Justia Law

The California Legislature reduced Medicaid hospital payments 10 percent between 2008-2011; the federal agency administering the Medicaid program approved the rate reductions. Hospitals alleged the reductions violated the Medicaid Act (42 U.S.C. 1396), which sets out procedural and substantive requirements the state must follow when establishing reimbursement rates. Hospitals unsuccessfully sought to have the rates declared void and almost $100 million in recalculated rates. The court of appeal affirmed, concluding that healthcare providers alleging a violation of section 1396a(a)(30)(A) may not obtain a writ of mandate against state officials to contest Medicaid rates approved by the federal agency that administers the program. Their recourse is an administrative action against the federal agency that approved the rates. While plaintiffs may obtain a writ of mandate for violations of the procedural requirements of section 13(A), no such violation occurred here. View "Santa Rosa Memorial Hospital v. Kent" on Justia Law

Memorial Hospital at Gulfport and Singing River Health System (“Hospitals”) sought judicial review of a June 24, 2016 administrative decision which found the Division of Medicaid’s (“DOM’s”) 2014 Fiscal Year Methodology “correctly interprets statutes and regulations and is neither arbitrary or capricious.” The chancellor affirmed the decision of DOM. Finding no evidence in the record before it that DOM failed to comply with Sections 43-13-117 and 43-13-145 in allocating and distributing supplemental payments to Mississippi hospitals, the Mississippi Supreme Court affirmed. View "Memorial Hospital at Gulfport v. Dzielak" on Justia Law